Texas Says Non-Residency Train Docs Can Say They're Board Certified in EM

[alphaholic06]

Dear EMRA members,

The Texas Medical Board has recently authorized diplomats of the American Board of Physician Specialties (ABPS) to advertise themselves as "board certified" in emergency medicine. ABPS does not mandate that its diplomats complete an approved residency training program in emergency medicine. Physicians in primary care specialties and anesthesia may become "board certified" in emergency medicine by ABPS after gaining experience in the field. EMRA maintains that the only pathway to board certification is through an approved ACGME or AOA emergency medicine residency training program. To read EMRA's policy regarding board certification, click here.

Here is our letter to the Texas Medical Board:

March 26, 2010
Re: ABPS/BCEM Board Certification

Dear Texas Medical Board:

The Emergency Medicine Residents' Association (EMRA) is the largest independent resident physician organization in the nation, promoting excellence in medical education and patient care since 1974. In representing over 90% of residents training in emergency medicine, we are deeply troubled by the recent decision allowing non-residency trained physicians in Texas to advertise themselves as "board certified" through the American Board of Physician Specialties (ABPS).

EMRA strongly believes that training in an accredited emergency medicine residency program is the only pathway to board certification. EMRA only recognizes the American Board of Emergency Medicine (ABEM) and the American Osteopathic Board of Emergency Medicine (AOBEM), both of which require residency training. The quality, caliber and depth of knowledge learned through a formal 3 to 4 year training program devoted to emergency medicine cannot be substituted by unsupervised experience on the field.

The ABPS, which is the governing body for the Board Certification of Emergency Medicine (BCEM), allows physicians trained in other specialties to represent themselves as "board certified" in emergency medicine to the public without completing an approved residency in the specialty. In a time when half a century of training skills have evolved into a specific, unparalleled and focused education the two are not comparable.

EMRA is greatly appreciative of the innumerable physicians who have helped staff hospitals nationwide for years and that began prior to the current availability of residency training programs. Nowadays, residency programs are widely available and have evolved significantly, going as far as producing subspecialties in emergency medical services (EMS), toxicology, emergency ultrasonography and disaster medicine to name a few. It is misleading to imply equivalency without residency training by asserting "board certification."

Emergency medicine is one of the more competitive specialties. Given the critical nature and the rapid analytical decisions that must take place, medical student applicants currently rank among the highest in their class. Alternative pathways of board certification will compromise this by allowing medical students that did not successfully gain entry into an emergency medicine residency program to complete another training program and still practice as "board certified" emergency physicians, a fact to which the majority of the public will not be aware.

Pediatricians are trained in pediatric residency programs, surgeons in surgery residency programs, anesthesiologists in anesthesia residency programs. Emergency medicine is a highly specialized field that must also retain and protect its requirement for focused residency training. The concept that we can cross specialties by on the field experience undermines our medical education and the nature of medical residency training.

None of these concerns is greater than that of public misconception. The lay public is not privy to the differences between "board certified", "board certified in ABPS" or "board certified in BCEM" and will assume that residency training in emergency medicine was achieved by the physician rendering care. This will prevent patients from making an informed decision regarding who they choose for their care.

We implore the Texas Medical Board to retract the position allowing ABPS-certified physicians to advertise themselves as "board certified", "board certified in ABPS", or "board certified in BCEM" for the reasons aforementioned. It would unknowingly be doing a great disservice to the thousands of physicians currently in emergency medicine residency training programs, the tens of thousands of residency trained physicians currently working in our communities and the millions of patients they serve.

Thank you for your consideration of this very important issue. Please feel free to contact us if you have any questions or need more information.


Respectfully,

Edwin Lopez, MD
President
Emergency Medicine Residents' Association

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[pinipig523]

Well that's no good.

 

[pinipig523]

119 views and no other comments. It's nice to know that no one else finds this alarming that our field is threatened by the fact that you dont have to do an ER residency to be BC.

 

[docB]

119 views and no other comments. It's nice to know that no one else finds this alarming that our field is threatened by the fact that you dont have to do an ER residency to be BC.

It's not that no one finds it alarming. It's that it's old news. Those of us that are currently fighting it are doing so via ACEP and ABEM.

 

[pinipig523]

It's not that no one finds it alarming. It's that it's old news. Those of us that are currently fighting it are doing so via ACEP and ABEM.

Well, that's good to hear, I was beginning to wonder what was going on.

So what's the outlook on this and possible reversal?

 

[7starmantis]

so what's the outlook on this and possible reversal?

+ 1

 

[Jeff698]

It's not that no one finds it alarming. It's that it's old news. Those of us that are currently fighting it are doing so via ACEP and ABEM.

I sent my letter in as soon as I was notified via TCEP and ACEP, almost simultaneously.

Take care,
Jeff

 

[deleted109597]

Yawn, not new.
However, if you haven't sent in your retort, I recommend doing it.

 

[docB]

Well, that's good to hear, I was beginning to wonder what was going on.

So what's the outlook on this and possible reversal?

Not good. The FL and TX boards have adopted the spin of "We're doing everything we can to put boarded EPs in your EDs." Since they're running with this sham to try to convince their poulations that they're doing the right think it's unlikley to change. This is as opposed to boards like NV that adopt highly restrictive stances to be able to say to the public "Look how hard we are on doctors, we must be protecting you." They both have their own drawbacks but allowing fake board certs is a bad idea.

 

[Raryn]

Not good. The FL and TX boards have adopted the spin of "We're doing everything we can to put boarded EPs in your EDs." Since they're running with this sham to try to convince their poulations that they're doing the right think it's unlikley to change. This is as opposed to boards like NV that adopt highly restrictive stances to be able to say to the public "Look how hard we are on doctors, we must be protecting you." They both have their own drawbacks but allowing fake board certs is a bad idea.

Are (reputable) hospitals hiring these people? If not, then are they any different than random FPs who will work in rural ERs whether or not they are "board certified"?

Don't mean to show my ignorance, just wondering if its making any big difference.

 

[docB]

Are (reputable) hospitals hiring these people? If not, then are they any different than random FPs who will work in rural ERs whether or not they are "board certified"?

Don't mean to show my ignorance, just wondering if its making any big difference.

No. Most hospitals that can require BC/BE docs require docs that are ABEM BC/BE. Those that can't require BC docs don't.

The worry is that this will have the effect of making hospital administrators more comfortable with the idea if allowing non-boarded/fake boarded docs into their EDs.

You notice that a lot of the wording for thses things revolves around who can advertise as a boarded doc, not so much who can practice. Most states are pretty liberal about what you can do once you're licensed. In theory I could go do brain surgery since I'm fully licensed. The mechanisms that are in place to stop me are those of facility credentialing (ie. no one would let me use their OR) and insurance (not to mention ethics and common sense). But who can advertise as what is often a BOM issue. So who cares? Hospital admins, that's who. If they can hire a bunch of cut rate docs and still advertise their ED as staffed with BC docs they'll do it. The public doesn't know ABEM from the ACLU.

 

[pinipig523]

No. Most hospitals that can require BC/BE docs require docs that are ABEM BC/BE. Those that can't require BC docs don't.

The worry is that this will have the effect of making hospital administrators more comfortable with the idea if allowing non-boarded/fake boarded docs into their EDs.

You notice that a lot of the wording for thses things revolves around who can advertise as a boarded doc, not so much who can practice. Most states are pretty liberal about what you can do once you're licensed. In theory I could go do brain surgery since I'm fully licensed. The mechanisms that are in place to stop me are those of facility credentialing (ie. no one would let me use their OR) and insurance (not to mention ethics and common sense). But who can advertise as what is often a BOM issue. So who cares? Hospital admins, that's who. If they can hire a bunch of cut rate docs and still advertise their ED as staffed with BC docs they'll do it. The public doesn't know ABEM from the ACLU.

I was looking at some ads for Texas positions and some list ABEM BC EM physician as a requirement. I really hope this doesn't hurt us. I would really hate to see FPs becoming EM docs through this route routinely.

 

[EMMudphud]

I was reading some other discussion boards that support this I found through google. Obviously, my position is clear given that I am beginning an EM residency in June. However, I was shocked by just how many posts on the pro-ABPS boards make the claim that FP, IM and Surgery trained people "make much better ER docs." Some of the posts were kind of infuriating and made me force myself to not reply. oh well...comes with the territory I guess. Go look for yourself. It is interesting to hear what the pro-ABPS people have to say. There is definately another side to this we obviously don't see on this board. I just happen to disagree with the other side.

 

[pinipig523]

I was reading some other discussion boards that support this I found through google. Obviously, my position is clear given that I am beginning an EM residency in June. However, I was shocked by just how many posts on the pro-ABPS boards make the claim that FP, IM and Surgery trained people "make much better ER docs." Some of the posts were kind of infuriating and made me force myself to not reply. oh well...comes with the territory I guess. Go look for yourself. It is interesting to hear what the pro-ABPS people have to say. There is definately another side to this we obviously don't see on this board. I just happen to disagree with the other side.

Are you effing kidding me? FP, IM, and Surg docs make better EM docs?

You don't see us claiming that EM docs make better FP/IM/Surg docs.

 

[MSmentor018]

I sent my letter in as soon as I was notified via TCEP and ACEP, almost simultaneously.

Take care,
Jeff

same here

 

[docB]

I was reading some other discussion boards that support this I found through google. Obviously, my position is clear given that I am beginning an EM residency in June. However, I was shocked by just how many posts on the pro-ABPS boards make the claim that FP, IM and Surgery trained people "make much better ER docs." Some of the posts were kind of infuriating and made me force myself to not reply. oh well...comes with the territory I guess. Go look for yourself. It is interesting to hear what the pro-ABPS people have to say. There is definately another side to this we obviously don't see on this board. I just happen to disagree with the other side.

Are you effing kidding me? FP, IM, and Surg docs make better EM docs?

You don't see us claiming that EM docs make better FP/IM/Surg docs.

I agree that this is a ridiculous claim but you have to understand the incentives at work here. The ABPS is selling a sham certification. They want more docs to pay them for their... uh, service. To do this they, as salesmen, use a pitch that is very attractive to a lot of docs, ER bashing.

ABPS: Hey Dr. Surgeon, don't you get a lot of bogus consults from the ED? Couldn't you do their job better than them?
Dr. Surgeon: Damn straight! They called called me the other day for an uninsured guy with a possible appy and they guy turned out not to have an appy. I'd be a much better ER doc than them! Sign me up. Here's my cash.

They tend not to dwell on the inconvenient issues with this.

Nurse: Hey Dr. Surgeon, ABPS EM Certified ER doctor! Come see this 2 month old with fever and lethargy.
Dr. Surgeon: Ummm...

But you can see how there'd be a market for that pitch.

The main pitch for the ABPS is to the docs that have been working in rural EDs for a while and want to advance their careers (bid a contract, move to a bigger hospital, etc.) and can't because they're not BC. They think it's unfair and they are the real target market for this travesty.

 

[reedman]

would i be wrong in thinking that only smaller ERs are gonna go for this, and the trauma centers will still demand AGME certification? i may be way off here, but i would bet that all the "big boy" ER docs are pretty safe from the competition, as any hospital would get AGME certified docs if it could.

 

[docB]

would i be wrong in thinking that only smaller ERs are gonna go for this, and the trauma centers will still demand AGME certification? i may be way off here, but i would bet that all the "big boy" ER docs are pretty safe from the competition, as any hospital would get AGME certified docs if it could.

Trauma center designation isn't the main factor here. It will have more to do with desirability of a location and payer mix. Those have always determined a hospital's ability to make demands.

It would be interesting to see how the various center certifying bodies (ie. chest pain, stroke, trauma, etc.) deal with this. For example to be a trauma center you have to have an EP on site. Do they specify a BC EP? Do they recognize ABPS or only ABEM? That might be an additional avenue to fight them.

 

[deleted109597]

The comic relief is that even though the ABPS has certifications for other specialties, 80% of the ones they do are for EM. Wonder why?

 

[reedman]

Trauma center designation isn't the main factor here. It will have more to do with desirability of a location and payer mix. Those have always determined a hospital's ability to make demands.

It would be interesting to see how the various center certifying bodies (ie. chest pain, stroke, trauma, etc.) deal with this. For example to be a trauma center you have to have an EP on site. Do they specify a BC EP? Do they recognize ABPS or only ABEM? That might be an additional avenue to fight them.

i see the potential for some hospital boosting its image and perhaps profits by using some ABPS cert docs to get trauma center status.

anyway, im sure in the end this will all come down to money; if the hospitals can profit, they will.

 

[Dwindlin]

The comic relief is that even though the ABPS has certifications for other specialties, 80% of the ones they do are for EM. Wonder why?

As I am a 1st year I knew very little about the ABPS so I went digging around their site. I found it a huge slap in the face that EM seems to be the only specialty that they will "certify" having not done a residency in that field. The whole thing is ridiculous.

 

[Old_Mil]

There's far less harm in an IM or FM trained physician boarding himself in Emergency Medicine than there is in a nurse practitioner calling herself a dermatologist. How long do you think its going to be before institutions start opening EM residencies for NPs? Let's not miss the forest for the trees. While ACEP sits and bickers about which physicians should be able to be EM boarded - we're completely unprepared for the salary and quality of life beatdown the entire medical profession is going to take if a nurse with 4 + 2 + 2 years of education is able to call herself an "Doctor specializing in Emergency Medicine."

 

[GeneralVeers]

we're completely unprepared for the salary and quality of life beatdown the entire medical profession is going to take if a nurse with 4 + 2 + 2 years of education is able to call herself an "Doctor specializing in Emergency Medicine."

Even scarier is that "Naturopathic Physicians" can now prescribe REAL medications in many states:

http://www.thefreelibrary.com/Oregon+legislature+passes+naturopathic+formulary+bill.-a0211561634

These people with a college degree and a BS degree in natural medicine will now be able to write for any prescription medications in the state of Oregon. Is anyone else as frightened by this as I am?

 

[Wahoowa23]

All that is required to practice medicine in the United States is a license to practice. Everything related to board certification is a way for guilds to protect their market, albeit under the rubric of patient safety. One could be a fantastic EM physician but based on the current system there is no avenue for that physician to be certified. Thus the creation of an alternate system. If ABEM had a validated alternate pathway for physicians with experience and ability to prove their knowledge (ie, by oral and written examination and possibly review of procedures/charts), then we would not even be discussing this. There are many faculty attendings that will train the future EM doctors who completed residencies in Surgery, IM or FM. Take Peter Rosen, MD as an example. The real issue in this country is that we don't graduate enough doctors to cover the front lines of medicine.

 

[emergentmd]

Why are you bringing up this thread? If you did not do an approved EM residency, you should not be board certified by the most well known board (ABEM). I don't really care if you are a good EM Doc or how much experience you have. There is a privilege and right that comes with board training. How else would you distinguish a EM trained vs FP trained EP? How would they laymen distinguish it? If all hospitals recognized 10 groups that certifies docs, then why even go through a residency?

Do you Intern year, go work in a rural ED for 1 yr, get boarded by "Phoenix board of medicine" and work in the same Pit that I do? Forget it

 

[TooMuchResearch]

All that is required to practice medicine in the United States is a license to practice. Everything related to board certification is a way for guilds to protect their market, albeit under the rubric of patient safety. One could be a fantastic EM physician but based on the current system there is no avenue for that physician to be certified. Thus the creation of an alternate system. If ABEM had a validated alternate pathway for physicians with experience and ability to prove their knowledge (ie, by oral and written examination and possibly review of procedures/charts), then we would not even be discussing this. There are many faculty attendings that will train the future EM doctors who completed residencies in Surgery, IM or FM. Take Peter Rosen, MD as an example. The real issue in this country is that we don't graduate enough doctors to cover the front lines of medicine.

Perhaps you have more recent examples? Rather than, you know, people who trained before EM residencies.

 

[Old_Mil]

I went to an ACGME EM residency, took the written and oral boards and passed them on the first try, and am keeping up with the LLSAs (even the loathed patient safety bit). I probably will lose board certification through ABEM at the end of ten years because the reality is that many of us work in environments where admin wants us to show up, shut up, and go home. There's no way I'm going to get any sort of practice improvement project done every five years. I've already proposed two possibilities for my first five year time window and neither has gotten anywhere. End result is that despite keeping up with the LLSAs, I won't be eligible to take the Concert. I'll probably seek out ABPS certification at that point as well.

 

[Psai]

Why are you bringing up this thread? If you did not do an approved EM residency, you should not be board certified by the most well known board (ABEM). I don't really care if you are a good EM Doc or how much experience you have. There is a privilege and right that comes with board training. How else would you distinguish a EM trained vs FP trained EP? How would they laymen distinguish it? If all hospitals recognized 10 groups that certifies docs, then why even go through a residency?

Do you Intern year, go work in a rural ED for 1 yr, get boarded by "Phoenix board of medicine" and work in the same Pit that I do? Forget it

https://www.bcencertifications.org/Get-Certified/CEN.aspx
http://www.acep.org/Clinical---Prac...cy-Nurse-Certifications-Do-Make-a-Difference/

Everyone and their mothers is a board certified residency and fellowship trained doctor nowadays
Many patients don't know what board certified means or the difference between dr. nurse dnp embcfecennrnsadnn and an actual emergency physician

 

[Vandalia]

I have to agree, no one cares.

Board certification will get you hired, but after that, all that matters is results. You can be a Caribbean-grad with 'state minimum' training, and provided you manage to worm yourself into a job somehow, if you keep the patients happy, don't kill anyone, and don't generate malpractice suits with decent productivity you will keep the job for life. On the other hand, you can have a gold plated background, and if you fail in those things, you will be out of the job in a month.

EM (along with perhaps radiology, pathology and anesthesiology) is the specialty where people don't care an iota about the background of the person they see. If that person can solve the patient's problem, great; if not, the letters after the name don't matter.

It is one of the great things about this specialty. You can't hide. You can either do the job, or you can't; and no matter what, everyone will know the answer to that right quick.

 

[Mbekweni]

I was thinking that as soon as I got tired of nights I could get ABPS board certified in Dermatology, freeze off some moles and move to a nice lake house outside of Austin.

 

[Arcan57]

Find the 10 busiest malpractice plaintiffs attorneys in your state and send them a list of the ABPS EM docs licensed in the state. Let market forces sort it out.

 

[Wahoowa23]

I have to agree as well. As long as you practice to the standard of care expected in the specialty then That is all that matters. I don't care who stabilized my mom at the rural ED where she presented before she went to the ICU -- I was happy the covering doc did so and she is now discharged. Thanks Dr Larson -- I could care less if you are FM, EM or Surgery trained. You knew how to interpret the blood gas and throw on the BIPAP preventing complete respiratory failure and need for a tube. That's the kind of Doc I want to be in the ED --Even if dispo is so much easier when they are tubed....

 

[deleted547339]

Holy necrobumps, Batman.

 

[WilcoWorld]

One could be a fantastic EM physician but based on the current system there is no avenue for that physician to be certified.

There is an avenue, and it's called residency.

There are many faculty attendings that will train the future EM doctors who completed residencies in Surgery, IM or FM. Take Peter Rosen, MD as an example.

Yes, please do take Peter Rosen as an example. The sort of attendings you describe are on their way out, but the fact remains - EM physicians need to continue to poach from every specialty's knowledge base, because if we do we'll continue to be better for it.

 

[emergentmd]

Sorry that I am a Board certified snob. I spend 3 years in an EM residency and thus got boarded by ABEM. If you want to be boarded in EM then go through an EM residency. I would love to be a dermatologist but I was never trained. Just because I can do biopsies and inject botox doesn't mean I should get boarded by some second tier Dermatology board.

I am proud that I was able to get in, get through a good EM residency. I should be afforded a higher status even if an unboarded doc has more experience and is a better doctor than me. I am happy that many hospitals require ABEM boarded EM docs bc that is the only way they can trust in the quality of the doctor.

 

[deleted77919]

…

 

[Vandalia]

There are a couple of subtle distinctions that need to be made here:

There was a "Grecian Urn" whose design had stumped scholars for centuries. Then, around 1990, a Harvard M.A. student thought he figured it out. The academic community rejected his ideas because he was just an M.A. student. Then, an art history luminary, who was an endowed professor at some Ivy League school said he agreed with the hypothesis, and everyone changed their mind - "Oh, that is the obvious interpretation."

There are still a few fields in medicine where there is no objective way to judge a physician's skill. Either the diagnosis/plan is simply a matter of debatable learned opinion, or the results are so far down the road that it is impossible to accurately evaluate them. In those specialties, the person with the best resume is judged to have the correct answer.

Emergency Medicine is not one of those. You cannot hide. Your skill - or lack thereof - is immediately apparent.

An EM residency is certainly the best preparation, and board certification is the best reference when applying for a job... however, that will only cover you for about a month. After that month, your reputation will be clear and that will determine your career path from that point on.

EM is a bit like the Air Force. In the Army, BPZ promotions for line officers are rare. However, the AF loves them and maxes out every board. As a pilot, your skill determines everything. ROTC, AFA, OCS, ANG, Reserve, Daedalians... doesn't matter. You either have it or you don't.

There are exceptions, but EM in most places is a ruthless meritocracy. A patient has no idea who they will see when they walk in the door (and if they ask, it is probably because they are a drug seeker.) The only thing they care about is if the appropriate care is delivered. I have yet to see an EM physician frame his diplomas and credentials and place them on an IV stand to wheel around with him when he sees a patient.

It is a subtle distinction, but it is an important one. An EM residency program provides far superior training, and I would take a random board certified EM physician over someone else 100% of the time. However, there are a few who despite the credentials are quacks. And there are even fewer who without the credentials are fully capable. And in the end, that is the only thing that matters.

 

[EM Junkie]

This is (obviously) a very old thread, and the TMB reconsidered shortly afterwards. As I understand it, a small number of docs got in under this system and were grandfathered, but it's now closed in TX.

http://m.chron.com/news/houston-tex...-settle-squabble-on-certification-1697023.php